Community Health Needs Assessment & Implementation Plan July 1, 2013 June 30, 2016 For Period FY - July 1, 2013 June 30, 2016 Page 1
Introduction and Purpose The Patient Protection and Affordable Care Act requires not-for-profit healthcare organizations to perform a Community Health Needs Assessment (CHNA) every three years and adopt an implementation strategy to meet the outstanding community health needs, identified therein, as a condition of maintaining the institution s federal tax exemption effective March 21, 2012. Wheaton Franciscan Healthcare Iowa (WFH-IA) has worked to develop a stand-alone assessment and implementation plan for each of its three hospitals; Mercy Hospital (Mercy), Oelwein; Sartori Memorial Hospital (SMH), Cedar Falls and Covenant Medical Center (CMC), Waterloo. It is designed to be a planning tool to assist in developing measurable strategic initiatives that can, over time, be improved and documented through third party data sources. Consistent with the organizational mission, history and heritage, the plan reviews health need findings and proposed implementation plans for Fayette County where the needs of the community were clear, and the ability of Mercy Hospital and WFH-IA to make a difference align. Fayette County represents 7.7% of the WFH-IA service population (US Census Bureau, 2010). Organization Overview Mercy Hospital was founded in 1926 in the town of Oelwein, Iowa by the Sisters of Mercy. In 1982, the Sisters of Mercy transferred sponsorship of the hospital to the Wheaton Franciscan Sisters. Today, Mercy Hospital provides service to Oelwein and surrounding communities including: Arlington, Maynard, Westgate, Oran and Fayette. 25-bed, critical access hospital including 24-hour, physician staffed emergency room Acute and outpatient care 39-bed, long-term care facility, Mercy Living Plus Mercy Ambulance Department 911 emergency responder for the City of Oelwein and surrounding communities Covenant Clinic staffed with physician and mid-level providers and outreach specialists Mercy and WFH-IA are part of Wheaton Franciscan Healthcare (WFH), a Catholic, and not-for-profit organization with nearly 100 health and shelter organizations in Wisconsin, Iowa, Colorado and Illinois. According to the Iowa Hospital Association, in FY 11, Mercy had an economic impact of nearly $10M on the local economy in Fayette County; meaning the hospital and the associates purchase a large amount of goods and services from local businesses. To get this value, the association uses the IMPLAN software tool which can analyze county level data using an economic input-output model. Employment and income (sum of payroll and employee benefits expense) are the important direct economic activities created from the hospital. For Period FY - July 1, 2013 June 30, 2016 Page 2
Our Mission Wheaton Franciscan Healthcare is committed to living out the healing ministry of the Judeo-Christian tradition by providing exceptional and compassionate health care that promotes the dignity and well-being of the people we serve. Community Health Needs Assessment Methodology In early 2013, WFH-IA focused on creating a community needs assessment that combined existing data with organizational experience. The WFH-IA team also used the Oelwein Area Health Needs Assessment Survey. The Survey was mailed/ hand delivered to 726 households: 216 were returned. Throughout this process, and this report, it was understood by the WFH-IA team that the community health needs assessments (CHNA) would result in three implementation plans, one for each hospital in the WFH-IA system, as required by the Patient Protection and Affordable Care Act. Process To complete the assessment, data was used from RWJ County Health Rankings & Roadmaps; the Oelwein Area Health Needs Assessment conducted by the Iowa State University Extension and Outreach Office; the Iowa Hospital Association and internal planning and utilization data; as well as informal interviews among health care professionals in the market place. Implementation Plan Adoption and Approval All the data, interviews and community input were compiled, reviewed and approved by the Wheaton Franciscan Healthcare Board of Trustees. Our value of stewardship calls us to focus our efforts and resources on identified health needs that Mercy can have the most impact. For Period FY - July 1, 2013 June 30, 2016 Page 3
Detailed Findings & Implementation Plan Access to Healthcare The Kaiser Family Foundation reports that in 2009, 419,600 residents of Iowa were considered poor, living 100% below the federal poverty guideline. Of those, 144,000 were children, 244,000 were adults and 31,200 were elderly. In the state, 380,600 people were Medicaid beneficiaries; 60% of them are children. Contrary to the Medicaid numbers, 341,200 people are uninsured; 85% are adults. As for Medicare, 485,519 people received Medicare benefits. Eighty-seven percent were 65 and older. The charts below detail the total number of people served through the Medicaid and Medicare programs at Mercy. Payments received from the government fall below the cost of treating public beneficiaries. The shortfall experienced for treating beneficiaries in FY 12 for the Medicaid program was $921,000; the shortfall for the Medicare program was $700,000. People Served through Medicaid FY 10 3,437 FY 11 3,809 FY 12 3,764 People Served through Medicare FY 10 12,583 FY 11 12,379 FY 12 12,003 Because of its geographic location, Mercy Hospital addresses the unique health needs of a very rural population, often different from those found in an urban setting. According to the National Rural Health Association (NRHA), economic factors, educational shortcomings, cultural and social differences, combined with the isolation of living in remote rural areas, all conspire to impede the struggle for rural Americans to lead healthy lives. NRHA lists ten factors that can affect rural American s access to health care: Shortage of health professionals in the area (2,608 people per one physician per the RWJ County Health Rankings, page 6) Lower income; poor (the rate of people living below the federal poverty level in Fayette County is 13.4%) Rely heavily on the Food Stamp Program (14.1% are food insecure in Fayette County) Abuse of alcohol and tobacco (25% and 22% respectively per the RWJ County Health Rankings, page 6) Shortage of dentists in the area (2,504 people per one dentist per the RWJ County Health Rankings, page 6) High incidence of hypertension (254 deaths due to hypertension in Fayette County in 2011) Suicide rate among rural men is significantly higher (eight people died from suicide in Fayette County in 2011) 2011 Vital Statistics Report Death and serious injury accidents account for 60% of total rural accidents versus 48% of urban. (Unintentional accidents were the sixth leading cause of death in Fayette County) 2011 Vital Statistics Report For Period FY - July 1, 2013 June 30, 2016 Page 4
Health Status Narrowing the scope of this plan was necessary, both in accordance with our organizational value of stewardship County Population % of MKT Pop RWJ Rankings Outcomes Factors Black Hawk 131,090 48.8% 77th 63rd Bremer 24,276 9.0% 9th 5th Butler 14,867 5.5% 47th 20th Benton 26,076 9.7% 14th 45th Tama 17,767 6.6% 53rd 64th Grundy 12,453 4.6% 22nd 7th Fayette 20,880 7.8% 54th 77th Buchanan 20,958 7.8% 42nd 52nd and to ensure the work proposed in the Implementation Plan, was meaningful and achievable. The 2013 Robert Wood Johnson (RWJ) County Health Rankings provide a model to measure health factors and health outcomes. County rankings are based on mortality, morbidity, health behaviors, clinical care, social/economic factors and physical environment. The scope of this assessment and implementation plan is focused to Fayette County as the primary service area for Mercy Hospital. Below are rankings in both Outcomes and Factors from the 2013 RWJ study that give direction and focus to efforts in improving community health. By study definition, health outcomes represent how healthy a county is while the health factors represent what influences the health of the county. For Period FY - July 1, 2013 June 30, 2016 Page 5
RWJ County Health Rankings The county rankings are based on mortality, morbidity, health behaviors, clinical care, social/economic factors and physical environment. Health outcomes represent how healthy a county is while the health factors represent what influences the health of the county. Fayette County Error Margin Iowa National Benchmark* Rank (of 99) Health Outcomes Mortality 54 60 Premature death 6,371 5,094-7,648 5,971 5,317 Morbidity 46 Poor or fair health 11% 7-16% 11% 10% Poor physical health days 3 2.1-3.9 2.8 2.6 Poor mental health days 3 2.0-4.0 2.7 2.3 Low birth weight 6.30% 5.1-7.5% 6.90% 6.00% Health Factors 77 Health Behaviors 87 Adult smoking 22% 17-28% 18% 13% Adult obesity 33% 28-39% 29% 25% Physical inactivity 26% 21-32% 25% 21% Excessive drinking 25% 19-32% 20% 7% Motor vehicle crash death rate 17 11-25 14 10 Sexually transmitted infections 216 346 92 Teen birth rate 28 23-32 32 21 Clinical Care 56 Uninsured 12% 11-14% 11% 11% Primary care physicians** 2,608:1 1,395:1 1,067:1 Dentists** 2,405:1 1,823:1 1,516:1 Preventable hospital stays 58 50-66 60 47 Diabetic screening 90% 80-100% 89% 90% Mammography screening 66% 55-76% 69% 73% Social & Economic Factors 65 High school graduation** 92% 88% Some college 62% 55-68% 68% 70% Unemployment 6.60% 5.90% 5.00% Children in poverty 19% 13-24% 17% 14% Inadequate social support 20% 14-27% 16% 14% Children in single parent household 24% 18-29% 27% 20% Violent crime rate 162 280 66 Physical Environment 46 Daily fine particulate matter 11.2 11.0-11.3 10.3 8.8 Drinking water safety 0% 5% 0% Access to recreational facilities 5 11 16 Limited access to healthy foods** 2% 6% 1% Fast food restaurants 30% 43% 27% * 90th percentile, i.e., only 10% are better. ** Data should not be compared with prior years due to changes in definition. Note: Blank values reflect unreliable or missing data For Period FY - July 1, 2013 June 30, 2016 Page 6
Overview of Findings The RWJ report for Fayette County, combined with the outcome of the Oelwein Area Health Needs Assessment commissioned by the city of Oelwein, point to three key areas in which Mercy Hospital could lead, or collaborate with current community efforts and how to have greatest impact on community health Low Birth Weight at 6.30% for the county, this indicator underperforms both state and national averages Health Behaviors as a grouping, the county rates 87 th out of Iowa s 99 counties offering multiple opportunities to foundationally improve the communities long term health Clinical Care ranked 56 th in Iowa, this, alongside Mercy s affiliation with Covenant Clinic points to an area the organization is uniquely positioned to influence. Exclusions While several areas listed in the RWJ County Health Rankings is of concern, the call to show focused, measureable results as a long term outcome of this plan, along with our organizational value of stewardship, means not every identified disparity/need will be part of this plan. While our efforts will be focused on specific actions within the health behaviors, clinical care and social support, areas of exclusion include: Teen Birth Rate/STI s Mercy, as part of Wheaton Franciscan Healthcare, adheres to the Social Responsibilities of Catholic Healthcare Services. While an important community issue, it was felt some of the options a community would be interested in discussing would be outside the scope of what we can provide. Motor Vehicle Crash Deaths while outside the scope of our provider mission, as a provider of emergency services in the community we would not lead, but could look to support and partner with other educational efforts in this area. Dental Care - outside the scope of our provider mission. Physical Environment - outside the scope of our provider mission. For Period FY - July 1, 2013 June 30, 2016 Page 7
Key Finding #1 Health Behaviors Per the RWJ County Health Rankings, Fayette County ranks 87 out of 99, significantly poorer than state and national averages. Measured behaviors influencing this ranking and related to our mission as a health care provider include adult smoking (22% versus an Iowa average of 18%), adult obesity (at 33%, opposed to 28% in the state), physical activity and excessive drinking (at 25%in the county versus 20% in Iowa and an 7% national benchmark). Each of these unhealthy behaviors lead to an increase in adverse health outcomes as seen by the Mercy Hospital providers and are opportunities, within our influence, expertise and available resources, to make a difference. Adult Smoking The adult smoking measure for the RWJ County Health Rankings is the estimated prevalence of the adult population that currently smokes every day or most days and has smoked at least 100 cigarettes in their lifetime. Using the measure, Fayette County ranks 22% percent, much higher than the national benchmark at 13%; and the state at 18%. According to the CDC, tobacco use remains the single largest preventable cause of disease, disability and death in the U.S. Between 2005 and 2010, more than three million Americans quit smoking, yet almost one in five adults still smoke, and one in five smokers will die in the U.S. from the habit. Tobacco usage among county residents coincides with national and state averages. However, smoking prevalence was highest in the Midwest at 21.8%, attributing to more chronic disease such as heart disease, lung cancer and emphysema, as well as low birth weight. Excessive Drinking Under the RWJ County Health Rankings, 25% of the population in Fayette County, as compared to the national benchmark of 7%, reported they either binge drink, defined as consuming more than four (women) or five (men) alcoholic beverages on a single occasion in the past 30 days, or drink heavily, defined as drinking more than one (women) or two (men) drinks per day on average. According to a study by the CDC, researchers found the costs largely resulted from losses in workplace productivity (72% of the total cost), health care expenses for problems caused by excessive drinking (11% of the total cost), law enforcement and other criminal justice expenses related to excessive alcohol consumption (9% of the total cost), and motor vehicle crash costs (deaths for Fayette County were 17) from impaired driving (6% of the total cost). The study did not consider a number of other costs such as those due to pain and suffering by the excessive drinker or others who were affected by the drinking, and thus may be an underestimate. Researchers estimated that excessive drinking cost $746 per person in the United States in 2006. Physical Inactivity Using the Behavioral Risk Factor Surveillance System (BRFSS) data (2009), a survey question was asked of 5,692 adult Iowans regarding their physical activity how much physical activity (20+ minutes of vigorous physical activity) do you get three or more days per week? Seventy-eight percent answered negatively, noting they do not get physical activity three or more days per week. Mercy Hospital CHNA and Implementation Plan For Period FY July 1, 2013 June 30, 2106 Page 8
The lack of physical activity, coupled with the obesity rate in Fayette County and the state, is cause for alarm. The BRFSS data indicated that Fayette County has 10 recreational facilities per 100,000 people, an extremely low and concerning number for the county. Recreational facilities are defined as establishments primarily engaged in operating fitness facilities featuring exercise and other physical fitness conditioning, and/or offering recreational sports activities such as swimming, skating or racquet sports. The availability of recreational facilities can influence individuals and communities choices to engage in physical activity. As outlined in the Oelwein Community Health Needs Assessment conducted in the fall of 2012, 94% of residents are aware of the Williams Wellness Center, yet only 6% are members, citing cost and awareness of offerings as a main factor for non-members. Key Finding #1 Health Behavior Strategies 1:1 Support programs to promote healthy behaviors among school aged children in the Mercy service area 1:2 Improve the health of under-insured patients diagnosed with cardiovascular related diseases in the Mercy service area. 1:3 Identify students in health classes at Oelwein High School and educate about heart health. Mercy Hospital CHNA and Implementation Plan For Period FY July 1, 2013 June 30, 2106 Page 9
Key Finding #2 Clinical Care In the area of clinical care, Fayette County ranks 56 out of 99 counties. The RWJ County Health Rankings report has the following in the clinical care category: uninsured; primary care physicians and dentists; preventable hospital stays and screenings, both diabetes and mammograms. The RWJ County Health Rankings indicates disparity and opportunity in the stated ratio of physicians to the population in Fayette County, nearly double in the county than the state. With an acknowledged shortage in training coupled with a diminished desire to practice in rural settings, recruitment of medical professionals to Fayette County is critical. The mammography screening measure represents the percent of female Medicare enrollees age 67-69 that had at least one mammogram over a two-year period. Evidence suggests mammography screening reduces breast cancer mortality, especially among older women. The percent of women ages 40-69 receiving a mammogram is a widely endorsed quality of care measure. Elmore, J. G., Armstrong, K., Lehman, C. D., Fletcher, S. W. Screening for breast cancer. JAMA. 2005;293(10):1245-1256. Key Finding #2 Clinical Care Strategies 2:1 Identify key medical professionals to provide primary care services at Covenant Clinic-Oelwein. 2:2 Increase well-woman screenings through awareness and education about the importance of early detection among Fayette County residents. Mercy Hospital CHNA and Implementation Plan For Period FY July 1, 2013 June 30, 2106 Page 10
Key Finding #3 Social Factors Of particular note in the RWJ County Health Rankings for Fayette County is inadequate social support. In the county, 20% felt they never, rarely or sometimes receive the support they need. Inadequate social support faired higher in Fayette County as compared to the national benchmark of 14% and the state average of 16%. Poor family support, minimal contact with others, and limited involvement in community life are associated with increased morbidity and early mortality. A 2001 study found that the magnitude of health risk associated with social isolation is similar to the risk of cigarette smoking (House JS. Social isolation kills, but how and why? Psychosom Med. 2001;63:273-274), a real concern as it relates to the aging population in this rural area, and their inability to access services due to transportation, overall health, etc. Furthermore, social support networks have been identified as powerful predictors of health behaviors, suggesting that individuals without a strong social network are less likely to make healthy lifestyle choices than individuals with a strong network. Another relative issue in this category is the number of children in single-parent households, emphasizing the need for health support of young women during and after pregnancy. Social support networks have been identified as powerful predictors of health behaviors, suggesting that individuals without a strong social network are less likely to make healthy lifestyle choices than individuals with a strong network. A study that compared BRFSS data on health status to questions from the General Social Survey found people living in areas with high levels of social trust are less likely to rate their health status as fair or poor than people living in areas with low levels of social trust (Kawachi IK, Bruce P, Glass R. Social capital and self-rated health: A contextual analysis. Am J Public Health. 1999;89:1187-1193). Key Finding #3 Social Factors Strategies 3:1 Provide health education to area senior citizens within Fayette County. 3:2 Educate high-risk populations about the importance of prenatal care and the impact of health behaviors to reduce incidences of low birth rate, and impact the overall health and well-being of mother/baby. Mercy Hospital CHNA and Implementation Plan For Period FY July 1, 2013 June 30, 2106 Page 11